Alcohol dehydrogenase (ADH) plus cytochrome P-450 2E1 (CYP2E1) convert ethanol into acetaldehyde which is then converted to acetate
CYP2E1 releases reactive oxygen species leading to inflammation
NAD+ is used as oxidizing agent for ADH and is converted to NADH
Excess alcohol creates an imbalance of NAD/NADH
Excess NADH decreases oxidation of fatty acid oxidation
While acetate increases fatty acid synthesis
Both leading to steatosis
Pts often present between 40-50 years of age
Classic presenting features
Abdominal distention due to ascites
Bruit can be appreciated over the liver due to increased hepatic blood flow
Moderate elevations of AST and ALT
Usually less than 300, rarely higher than 500
AST:ALT ratio >2
ALT is less due to alcohol induced deficiency of Pyridoxal 5-phosphate, which is a coenzyme of ALT. Thus the ratio reflects the failure to appropriately increase the ALT, rather than an inappropriate increase in AST.
Elevated Tbili and Dbili
Leukocytosis (usually <20) with a neutrophil predominance
Extreme Leukemoid reaction (>50) is associated with a very poor prognosis.
Reflective of poor nutritional status
Imaging (show pics!)
1st choice: Abdominal ultrasound
It’s quick, easy, and relatively cheap
Will help rule out Budd-Chiari, abscess, obstruction, or neoplasm
Will show fatty changes in liver vs underlying cirrhosis
Maddrey Discriminant Function
DF >32 signifies severe alc hep and is associated with high short-term mortality
May benefit from glucocorticoid therapy
3 main things
Check Lille Score on day 7 to evaluate response
>.45 is associated with 6-month survival of 25% –> ok to stop steroids
<.45 is associated with 85% survival
Pentoxyfilline –> little evidence!
The Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial was just published in the New England Journal in 2015.
They found a significant 28 day mortality benefit for prednisolone with an odds ratio of .61.
However, the mortality benefit was lost at 90 days and 1 year
On the other hand, pentoxifylline did not improve survival compared to placebo